BACKGROUND
The majority of thyroid cancers have an excellent prognosis; they are curable by surgery and not associated with cancer recurrence and death. These are called low-risk thyroid cancers. In the past several years, medical guidelines changed their position regarding the extent of treatment for these cancers. Total thyroidectomy (removing thyroid gland completely) and radioactive iodine therapy are not recommended any more for management of thyroid nodules exhibiting characteristics of a low-risk cancer. Instead, the adopted recommendation is now lobectomy (removing one lobe of thyroid gland). Despite the changes in guidelines, many low-risk thyroid cancers in the United States are still managed by total thyroidectomy. This is considered over-treatment and may be associated with unnecessary complications.

Patient’s anxiety is one of the known factors affecting the decisions regarding management of their medical problems. The goal of this study was to describe the emotional content of patient-surgeon conversation prior to surgery in patients thought to have low-risk thyroid cancer.

THE FULL ARTICLE TITLE
Pitt SC et al 2021 The influence of emotions on treatment decisions about low risk thyroid cancer: A qualitative study. Thyroid. Epub 2021 Oct 12. PMID: 34641715.

SUMMARY OF THE STUDY
This study was done in 2 university hospitals. Thyroid surgeons and their patients were invited to participate and their conversation prior to surgery was recorded and then transcribed. A total of 9 surgeons joined the study; they were in practice for 5-50 years, 67% of them were male and 67% were white. Overall, 30 patients participated in this study. They were all English-speaking, with thyroid nodules with evidence of low-risk cancer prior to surgery. The average age of patients was 48.5 and the range was 20-71 years. Of these patients, 87% were white and 80% were women.

Low risk cancer was defined as a thyroid nodule smaller than 4 cm which was proven to be papillary thyroid cancer or highly suspicious for papillary thyroid cancer by biopsy. In addition, there was no evidence of spread of the cancer to the lymph nodes in the neck or extension of cancer beyond the thyroid gland by imaging studies done prior to surgery.

Patients completed a validated Cancer Worry Scale and 80% expressed worry and anxiety. The source of anxiety for patients were cancer diagnosis (the C word), the possibility of recurrence and advancement of the cancer, potential complications from treatment (for example, change of voice, scar) and taking thyroid hormone for life. In response, most surgeons tried to provide re-assuring information backed by research. However, at times, they missed the opportunity to respond with empathy. When responding with empathy they reminded patients that they would not be abandoned and provided resources and empathic gestures. At the time of preparation of this article, 11 patients had total thyroidectomy, 2 had partial thyroidectomy, 10 were not able to decide and 7 decided to have active surveillance (monitoring the cancer by thyroid ultrasound and deferring surgery).

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
The authors concluded that most patients express negative emotions and anxiety when discussing the treatment options with their surgeons. In response, education regarding the low probability of harm by a low-risk thyroid cancer is provided by surgeons, but some miss the opportunity to offer empathy in addition to teaching. Both patients and surgeons agreed that patient anxiety is one of the reasons total thyroidectomies is chosen over lobectomy.

— Shirin Haddady, MD MPH

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